乳腺癌术中反向腋窝淋巴作图研究进展

腋窝反向淋巴作图是国外近两年提出的旨在保护上肢淋巴回流通路的一项新的微创技术,其目的在于通过作图示踪上肢淋巴回流通路,术中尽量予以保护,从而减少上肢水肿这一乳腺癌术后常见并发症的发生.     

染料法腋窝反向淋巴作图300例临床研究

  目的  研究腋窝反向淋巴作图（axillary reverse mapping,ARM）对上肢淋巴回流管网的辨别和保护作用及对减少腋窝淋巴结清扫术后上肢水肿的作用。  方法  选取2009年6月至2011年5月蚌埠医学院第一附属医院肿瘤外三科300例单侧乳腺癌患者,在进行腋窝淋巴结清扫前,经上臂内侧肌间沟皮下注射亚甲蓝2~3 mL,对上肢来源的淋巴管和淋巴结进行染色,术中加以辨别和保护。术后2个月测量双上臂周径差异（患侧臂周径-健侧臂周径≥2 cm为淋巴水肿）,记录淋巴水肿的发生情况。  结果  300例患者中有195例作图成功,成功率65%。分别于术后6、12、18、24个月进行随访,发现和同期作图失败患者相比较,作图成功患者淋巴水肿的发生率明显降低,差异具有显著性统计学意义。  结论  通过腋窝反向淋巴作图（ARM）可以辨别保护上肢回流的淋巴管道,对预防乳腺癌腋窝淋巴结清扫术后上肢水肿具有临床意义。      

染料法腋窝反向淋巴作图在早期乳腺癌手术中的应用及分析

目的 研究影像学检查腋窝阴性的浸润性乳腺癌患者,行染料法腋窝反向淋巴作图（axillaryreverse mapping, ARM）,探讨影响其成功率的影响因素,并比较保留ARM淋巴结的腋窝淋巴结清扫术(axillary lymph node dissection, ALND)与常规ALND术后上肢淋巴水肿的发生率,分析其危险因素。方法 对50例确诊为浸润性乳腺癌,并且术前影像检查腋窝阴性的患者,于术中向患侧上臂内侧皮下及肌肉内注射亚甲蓝染料约2 ml。观察上肢的淋巴管道及淋巴结的显影情况,并对显影的淋巴管道及淋巴结予以保留,比较保留ARM淋巴结的ALND与ARM失败后的ALND术后上肢的淋巴水肿发生率,并且对其潜在因素,如年龄及体质量指数,做正态性检验、t检验及多因素Logistic回归分析。结果 50例中ARM成功的有34例(68%),ARM未成功的有16例(32%)。术中观察保留ARM淋巴结的患者体质量指数及上肢淋巴水肿程度均低于术中ARM失败的患者（P均=0.01）,而与年龄无关（P=0.56）。去除混杂因素后的多因素分析表明,术中是否能显示并保留ARM淋巴结,是影响上肢淋巴水肿的独立危险因素（P=0.02,OR=16.39）,ARM失败的ALND,术后上肢淋巴水肿发生的危险度是保留ARM淋巴结的ALND的16.4倍。结论 乳腺癌术中保留ARM淋巴结,可以有效降低ALND后上肢淋巴水肿的发生。     

博莱霉素局部注射预防乳腺癌术后腋窝淋巴积液的应用

目的探讨乳腺癌患者手术合并腋窝淋巴清扫术后腋窝积液的发生原因与局部注射博莱霉素的效果和副作用。方法对65例乳腺癌患者手术,手术同时进行腋窝淋巴组织、锁骨下、胸大小肌之间淋巴组织清扫,并沿腋静脉、锁骨下静脉走向注射博莱霉素30 mg。结果术后患者适当延长腋窝引流时间,全组患者无腋窝积液,局部无感染。结论通过合理的术前准备、恰当的术中操作和术后护理可以降低乳腺癌患者术后腋窝淋巴积液的发生。     

降低乳腺癌术后淋巴水肿新技术——腋窝反向淋巴制图的研究进展

腋窝反向淋巴制图(axillary reverse mapping, ARM)技术是指在腋窝淋巴结切除术(axillary lymph node dissection, ALND)和/或前哨淋巴结切除术(sentinel lymph node dissection, SLND)中显示上肢淋巴管道并对其予以保护, 从而降低术后上肢淋巴水肿发生率, 是针对乳腺癌手术治疗的一项新兴技术, 目前仍处于临床试验阶段。本文回顾了近年来国外相关临床试验, 分析ARM淋巴结和淋巴管的显示方法, 评估保留ARM淋巴结和淋巴管的可行性, 评价ARM技术对降低乳腺癌术后上肢淋巴水肿发生率的临床意义。      

早期乳腺癌染料法前哨淋巴结活检的研究进展

全文从前哨淋巴结活检的历史出发,论述国内外有关染料法行早期乳腺癌前哨淋巴结活检的研究现状。     

腋窝逆向淋巴示踪预防乳腺癌患者上肢淋巴水肿的研究

目的：探讨乳腺癌前哨淋巴结活组织检查（ SLNB）或腋窝淋巴结清扫（ ALND）过程中,进行腋窝逆向淋巴示踪（ ARM）以保留引流上肢淋巴液的腋窝淋巴结的可行性,及其对术后上肢淋巴水肿的预防作用。方法选择2012年1月至2013年6月本科71例全乳房切除术＋前哨淋巴结活组织检查术患者（ SLNB组）和134例乳腺癌改良根治术患者（ ALND组）进行临床研究。将SLNB组和ALND组分别随机分为对照组和示踪组,即：SLNB对照组36例,SLNB示踪组35例;ALND对照组64例,ALND示踪组70例。 SLNB示踪组和ALND示踪组的手术方式除与其对照组相同外,还需进行ARM以保留引流上肢淋巴液的腋窝淋巴结（ ARM淋巴结）。前哨淋巴结和ARM淋巴结定位方法如下：术前2 h,在患者乳房肿块周围及患侧上臂内侧皮下注射^99Tc^m-Dx标记的同位素,并于术前5 min在患侧上臂内侧皮下注射2 ml亚甲蓝进行ARM淋巴结显色,术中用同位素γ探测仪探测放射性核素热点进行前哨淋巴结定位,并用γ探测仪结合蓝色染料定位ARM淋巴结。术中注意观察ARM淋巴结蓝染情况及其与前哨淋巴结有无重合,若无重合则保留所有蓝染的ARM淋巴结,若有重合则同时切除前哨淋巴结和ARM淋巴结;术后统计切除的淋巴结数量、术中出血量、置管时间、引流液体量及手术时间。术后6个月随访两组患者上肢淋巴水肿的发生情况。定量资料分析采用 t检验,定性资料比较采用秩和检验或χ^2检验。结果在SLNB示踪组35例患者中,26例（74．29%,26/35）术中检测到ARM淋巴结,其中1例患者前哨淋巴结与ARM淋巴结重合,此患者在SLNB过程中也接受了ARM淋巴结切除,因此SLNB示踪组ARM淋巴结保留率为71．43%（25/35）。在ALND示踪组70例患者中,67例（95．71%,67/70）术中检测到ARM淋巴结,其中5例患者前哨淋巴结与ARM淋巴结重合,此部分患者在ALND过程中同时接受ARM淋巴结切除,因此ALND示踪组ARM淋巴结保留率为88．57%（62/70）。在SLNB对照组与SLNB示踪组之间以及ALND对照组与ALND示踪组之间,腋窝淋巴结切除数量、术中出血量、术后引流液体量及置管时间的差异均无统计学意义（ t=-1．136、-0．570、0．032、0．903,P=0．264、0．570、0．975、0．370;t=1．149、0．416、1．405、-0．547,P=0．253、0．678、0．162、0．585）,但是SLNB示踪组和ALND示踪组的手术时间均长于其对照组[（90．26±6．04） min比（86．61±5．62） min,t=-2．616,P=0．011;（112．24±7．94） min比（92．33±6．88） min,t=-15．399,P=0．000]。术后随访6个月：SLNB对照组与SLNB示踪组上肢淋巴水肿发生率分别为11．11%（4/36）和8．00%（2/25）,两者间差异无统计学意义（P=1．000）;ALND对照组与ALND示踪组上肢淋巴水肿发生率分别为31．25%（20/64）和6．45%（4/62）,两者间差异有统计学意义（χ2=12．560,P=0．000）。结论乳腺癌患者行SLNB或ALND的过程中可以行ARM。 SLNB过程中保留ARM淋巴结对降低术后上肢淋巴水肿发生率无意义,而ALND过程中保留ARM淋巴结可有效降低术后上肢淋巴水肿发生率。     

乳腺癌腋窝淋巴结跳跃式转移的临床病理研究

目的 探讨乳腺癌腋窝淋巴结跳跃式转移与患者临床病理特征的关系及其对预后的影响.方法 回顾性分析1502例行完全腋窝淋巴结清除术乳腺癌患者的临床资料,观察腋窝淋巴结跳跃式转移的发生规律,分析其与患者临床病理特征的关系及对预后的影响.结果 有淋巴结转移者814例,其中腋窝淋巴结跳跃式转移者119例,占14.6%;跳跃式转移中,最常见的是从第Ⅰ、Ⅱ水平跳过第Ⅲ水平至腋尖,发生率为5.2%.跳跃式转移的发生与患者的年龄、肿瘤大小、临床分期以及雌激素受体状态均无关(均P＞0.05).Ⅰ～Ⅱ期患者中,跳跃式转移组的10年无病生存率较非跳跃式转移组低(58.5%∶ 77.3%,P＝0.003);Ⅲ期患者中,两组的10年无病生存率差异无统计学意义(50.0%∶ 57.6%,P＝0.457).Cox多因素分析显示,肿块大小、淋巴结转移数目、淋巴结结外是否受侵及是否发生跳跃式转移,是影响患者预后的独立因素.结论 某些常见的临床病理指标尚不能准确地预测腋窝淋巴结跳跃式转移的发生;早期乳腺癌发生跳跃式转移者预后差,对其应坚持严格而规范的治疗.     

腋窝淋巴结阴性年轻乳腺癌患者的远期生存分析

摘 要：［目的］ 分析腋窝淋巴结阴性年轻乳腺癌患者的远期生存和影响预后的因素。［方法］ 1997年1月至2004年12月共手术治疗101例腋窝淋巴结阴性年龄≤35岁的乳腺癌患者。通过病例记录和系列随访收集患者的临床病理资料和生存情况。生存率计算采用Kaplan-Meier法,组间比较采用Log-rank检验,多因素预后分析采用Cox比例风险模型。［结果］ 中位随访12.18 年 (0.18~19.47年),全组共有3例患者失访,10例发生局部复发和/或区域淋巴结转移,10例远地转移（其中6例同时伴有区域复发）,11例第二原发恶性肿瘤,13例患者死亡。全组10年无病生存率、无疾病复发生存率、无远地转移生存率和生存率分别为70.0%、75.1%、83.4% 和 87.2%。淋巴结解剖个数≤10个是影响生存的因素(P=0.036)。肿瘤大小是影响疾病复发的独立因素(P=0.050),但对远地转移和生存均无影响。［结论］ 腋窝淋巴结阴性年轻乳腺癌患者的远期预后尚好,肿瘤大小和腋窝淋巴结解剖个数分别是疾病复发和生存的影响因素。     

乳腺癌染料法前哨淋巴结活检的临床意义

前哨淋巴结活检 (ｓｅｎｔｉｎｅｌｌｙｍｐｈｎｏｄｅｂｉｏｐｓｙ,ＳＬＮＢ)技术的临床应用 ,有可能改变乳腺癌外科治疗中常规行腋窝淋巴结解剖 (ａｘｉｌｌａｒｙｌｙｍｐｈｎｏｄｅｓｄｉｓｓｅｃｔｉｏｎ ,ＡＬＮＤ)这一历史[1] 。我科自 2 0 0 0年 7月以来 ,采用 1%异硫蓝 (1%ｉｓｏｓｕｌｆａｎｂｌｕｅ)对5 2例乳腺癌患者开展了ＳＬＮＢ ,现将结果报告如下 ,并就其临床价值进行初步探讨。一、资料与方法1 一般资料 :本组 5 2例均为女性。年龄 38～ 74岁 ,平均 5 1.3岁。Ｔ134例 ,Ｔ2 18例 ,腋淋巴结扪诊均未见肿大。全组行乳腺癌改…     

Selective axillary dissection after axillary reverse mapping to prevent breast-cancer-related lymphoedema

Background

It has recently been reported that, using axillary reverse mapping (ARM), the lymphatics from the arm can be spared to reduce the incidence of breast-cancer-related lymphoedema (BCRL). The aim of this study was to assess the feasibility of selective axillary dissection (SAD) after using ARM and partially preserving arm drainage, and to assess the occurrence of BCRL.

Methods

Using a radioisotope and lymphoscintigraphy, ARM was performed in 60 patients scheduled for SAD, who were subsequently divided for the purpose of comparing the BCRL rates into: group A, comprising 45 patients who successfully underwent SAD with a residual lymphatic hot spot; and group B with 15 whose hot nodes were removed as is normally the case during complete axillary lymph node dissection (ALND).

Results

SAD was feasible in 75% of the 60 patients. SAD was completed successfully in 19 of the first 30 patients, and in 26 of the second 30 patients (p = 0.072). The median follow-up was 16 months (6–36), during which 9 patients developed a BCRL, 4 in group A (9%) and 5 in group B (33%); p = 0.035. None of the patients had nodal relapses during the follow-up.

Conclusions

Using a radioisotope enables an effective and safe SAD in a large proportion of patients. There was evidence of a trend to suggest a learning curve. The rate of BCRL after SAD was less than one third of the rate recorded after ALND, a result that should encourage the development of the former technique.     

Oncological safety of selective axillary dissection after axillary reverse mapping in node-positive breast cancer

IntroductionAlthough the need for axillary lymph node dissection (AD) is decreasing in breast cancer patients, it remains necessary in some cases. Axillary reverse mapping (ARM) enables the detection of upper extremity lymphatic drainage that may be spared during selective axillary dissection (SAD) so as to reduce the risk of lymphedema.The ability of the ARM-SAD procedure to reduce the incidence of lymphedema is being tested in an ongoing randomized trial. Crossover between arm drainage and breast drainage is well documented in the axilla, however, and whether the procedure is oncologically safe remains controversial. We aim to assess the axillary failure rate when a few nodes draining the upper arm are being spared by the ARM-SAD.MethodsWe report oncological outcomes, and axillary failure in particular, in the first 100 consecutive axillary node-positive patients treated with ARM-SAD as part of a pilot study and a randomized trial.ResultsA median of 18 (IQR 14–22) axillary nodes were excised per patient. During the follow-up (median 51 months, IQR 34–91), 11 patients experienced a treatment failure, but only one - treated with neoadjuvant chemotherapy - developed overt axillary disease as a first (and isolated) event. The crude rate of axillary failure was 1.36% (95% CI: 0.19–9.63) with an estimated 5-year crude cumulative incidence of 1.85% (95% CI: 0–5.47%).ConclusionsThe axillary failure rate was low in our patients and did not exceed rates reported in the literature after standard AD, thus indicating that the ARM-SAD procedure is oncologically safe.     

The influence of axillary reverse mapping related factors on lymphedema in breast cancer patients

Purpose

Upper extremity lymphedema (LE) is a harmful breast cancer complication. It has been reported that patient- or treatment-related risk factors of LE. Axillary reverse mapping (ARM) has been performed to prevent LE during axillary lymph node dissection (ALND) by visualizing the upper extremity lymphatics. We investigated whether ARM related factors included novel predictive risk factors of LE.

Methods

ARM revealed fluorescent axillary nodes (ARM nodes) in 76 patients by fluorescence imaging. Only ARM nodes within the ALND field were removed. Twenty-four (32%) patients developed LE (LE+) and 52 did not (LE−) during a median 24-month post-surgical follow-up period. We retrospectively evaluated the clinical features and ARM factors of LE+ and LE−.

Results

The positive ARM node rate among LE+ was 42%, significantly greater frequency than that among LE− (13%: p ≤ 0.05). Cranial collectors (lymphatic ducts along or above the axillary vein) were significantly more frequent in LE− (44%) than in LE+ (21%: p ≤ 0.05). Multivariate analysis revealed postoperative radiation and positive ARM nodes to be positive risk factors and cranial collectors to be a negative risk factor of LE.

Conclusions

ARM factors could predict the incidence of LE post-axillary surgeries in breast cancer patients.     

A patient- and assessor-blinded randomized controlled trial of axillary reverse mapping (ARM) in patients with early breast cancer

BackgroundAxillary lymph node dissection (ALND) in breast cancer patients is infamous for its accompanying morbidity. Selective preservation of upper extremity lymphatic drainage and accompanying lymph nodes crossing the axillary basin - currently resected during a standard ALND - has been proposed as a valuable surgical refinement.MethodsPeroperative Axillary Reversed Mapping (ARM) was used for selective preservation of upper extremity lymphatic drainage. A multicentre patient- and assessor-blinded randomized study was performed in clinical node negative, sentinel node positive early breast cancer patients. Patients were randomized to undergo either standard-ALND or ARM-ALND. Primary outcome was the presence of surgery-related lymphedema at six, 12 and 24 months post-operatively. Secondary outcomes included patient reported and objective signs and symptoms of lymphedema, pain, paraesthesia, numbness, loss of shoulder mobility, quality of life and axillary recurrence risk.ResultsNo significant differences were found between both groups using the water displacement method with respect to measured lymphedema. ARM-ALND resulted in less reported complaints of lymphedema at six, 12 and 24 months postoperatively (p < 0.05). No axillary recurrence was found in both groups.ConclusionsIn contrast to results of volumetric measurement, patient reported outcomes support selective sparing of the upper extremity lymphatic drainage using ARM as valuable surgical refinement in case of ALND in clinically node negative, sentinel node positive early breast cancer. If completion ALND in clinically node negative, sentinel node positive early breast cancer is considered, selective sparing of upper extremity axillary lymphatics by implementing ARM should be carried out in order to reduce morbidity.     

Axillary reverse mapping in patients undergoing axillary dissection -a short review of the literature

Axillary lymph node dissection (ALND) can be avoided not only in patients with negative sentinel lymph nodes (SLNs) but also in those with one or two positive SLNs receiving breast or axillary radiation. However, ALND has remained the standard treatment for patients with clinically positive nodes (cN+). Although axillary reverse mapping (ARM) was developed to map and preserve arm lymphatic drainage during ALND, it could not be indicated for cN + patients because metastatic rate of ARM nodes is high. However, a new type of conservative ALND with ARM attempts to preserve ARM lymphatics and nodes except SLNs and other suspicious palpable nodes, including suspicious ARM nodes. This procedure allowed reduction of the rate of arm lymphedema without increasing axillary recurrence, although patients received postoperative chemotherapy and high-risk patients underwent axillary radiation. Thus, a traditional full ALND may not be necessary for cN + patients in the era of effective multimodality therapy.     

Axillary reverse mapping using near-infrared fluorescence imaging in invasive breast cancer (ARMONIC study)

BackgroundAxillary lymph node dissection (ALND) in patients with breast cancer has potential side effects, including upper-limb lymphedema. Axillary reverse mapping (ARM) is a technique that enables discrimination of the lymphatic drainage of the upper limb in the axillary lymph node basin from that of the breast. We aimed to evaluate ARM node identification by near-infrared (NIR) fluorescence imaging during total mastectomy with ALND and then to analyze potential predictive factors of ARM node involvement.MethodsThe study enrolled 119 patients diagnosed with invasive breast cancer with an indication for ALND. NIR imaging using indocyanine green dye was performed in 109 patients during standard ALND to identify ARM nodes and their corresponding lymphatic ducts.Results94.5% of patients had ARM nodes identified (95%CI = [88.4–98.0]). The ARM nodes were localized in zone D in 63.4% of cases. Metastatic axillary lymph nodes were found in 55% in the whole cohort, and 19.4% also had metastasis in ARM nodes. Two patients had metastatic ARM nodes but not in the remaining axillary lymph nodes. No serious adverse events were observed. Only the amount of mitosis was significantly associated with ARM node metastasis.ConclusionsARM by NIR fluorescence imaging could be a reliable technique to identify ARM nodes in real-time when ALND is performed. The clinical data compared with ARM node histological diagnosis showed only the amount of mitosis in the diagnostic biopsy is a potential predictive factor of ARM node involvement.Clinical trial registrationNCT02994225.     

Lymphatic mapping in patients with primary or recurrent breast cancer following previous axillary surgery

Aims

To evaluate the feasibility of lymphatic mapping in breast cancer patients after previous axillary surgery and to identify parameters associated with mapping failure.

Methods

Lymphatic mapping using peritumoural injection of blue dye and a radiocolloid was attempted in 30 patients with primary (n = 7) or recurrent (n = 23) breast cancer and a history of previous axillary lymph node dissection or sentinel node biopsy.

Results

Lymphatic mapping identified a mean number of 1.6 (range 1–3) lymph nodes in 19 of 30 patients (identification rate 63%). The lymph nodes were removed from the ipsilateral axilla (n = 13), the internal mammary chain (n = 2), both the internal mammary nodes and the axilla (n = 2), the interpectoral space (n = 1) and the contralateral axilla (n = 1). Four of 19 patients revealed a positive lymph node. Fifteen of 19 patients had a negative lymph node. Axillary lymph node dissection was done in 13 of 15 patients but found no positive nodes (false negative rate = 0). A negative lymphoscintigram (p < 0.001) and a number of more than 10 lymph nodes removed at the time of initial surgery (p = 0.02) were significantly associated with a mapping failure.

Conclusion

Lymphatic mapping following prior axillary surgery was accurate but associated with a low identification rate. The lymphatic drainage pattern was unpredictable and the use of a radionuclide was necessary for a successful mapping procedure.